undefined

LGBT Health and Wellness Intake Form

This form is to be used by medical professionals when collecting health information from LGBT patients. It includes questions about the patient's sexual orientation and gender identity, as well as their health history. This form is important in ensuring that LGBT patients receive culturally competent care.

1 minute to complete

Eligibility

You may fill out an LGBT Health and Wellness Intake Form if you identify as lesbian, gay, bisexual, transgender, queer, questioning, or intersex.

undefined

Questions for LGBT Health and Wellness Intake Form

Questions

1.

How do you identify your gender?

The answer should be a text input.
2.

What is your age?

The answer should be a text input.
3.

What is your current relationship status?

The answer should be a single choice:
  1. Single
  2. Married
  3. Separated
  4. Divorced
4.

Do you have any children?

The answer should be a single choice:
  1. Yes
  2. No
5.

What is your occupation?

The answer should be a text input.
6.

What is your highest level of education?

The answer should be a single choice:
  1. High school diploma
  2. Graduation
  3. Post-Graduation
  4. Doctoral
7.

Are you sexually active?

The answer should be a single choice:
  1. Yes
  2. No
8.

Do you have any sexually transmitted infections?

The answer should be a single choice:
  1. Yes
  2. No
9.

Do you have any allergies?

The answer should be a single choice:
  1. Yes
  2. No
10.

Do you have any chronic health conditions?

The answer should be a single choice:
  1. Yes
  2. No

Forms Similar to LGBT Health and Wellness Intake Form

  • LGBT Health and Wellness Questionnaire
  • LGBT Health and Wellness Screening Form
  • LGBT Health and Wellness Profile Form
  • LGBT Health and Wellness Survey

Here are some FAQs and additional information
on
LGBT Health and Wellness Intake Form

Why is this intake form necessary?

This intake form is necessary to provide the best possible care for you. The information you provide will help us understand your health concerns and develop a plan of care that is tailored to your needs.

What information will I need to provide?

You will need to provide your contact information, medical history, and any other relevant information that will help us understand your health concerns.

What if I don’t want to provide some of the information requested in the intake form?

You are not required to provide any information that you do not feel comfortable sharing. However, the more information you are able to provide, the better we will be able to serve you.

How will my information be used?

Your information will be used to develop a plan of care that is tailored to your needs. It will also be used to track your progress and to ensure that you are receiving the best possible care.

Want to use this template?

Loved by people at home
and at work

undefined
“BlockSurvey is a simple, effective, and scalable tool for creating surveys for leadership and learning assessment. It's one of this year's best buying choices. Each month, it keeps improving and strives to serve its customers needs.”
Nelson Emilio
Personal Branding Strategist
undefined
“I use BlockSurvey to get feedback about all my activities and events. It is really easy to get started and create my first surveys! Then I could see how easy it was to share them. Now I am thinking to use BlockSurvey also within my creative process as an author in order to listen and engage with my audience, knowing that anonymity provides the most sincere and reliable answers.”
Georgina García-Mauriño
Author & Designer
BlockSurvey social proof
G2 Crowd
4.8 Star Rating
BlockSurvey social proof
Dapp.com
Editor's choice
BlockSurvey social proof
Capterra
4.9 Star Rating

What's next? Try out templates like
LGBT Health and Wellness Intake Form

1000+ Templates, 50+ Categories

Want to create secure online forms and surveys?

Join BlockSurvey.

SHARE